A problem describes a situation with regard to an individual’s health and/or welfare. This situation can be described by the person involved (the patient) themselves (in the form of a complaint), or by their healthcare professional (in the form of a diagnosis, for example). The situation can form cause for diagnostic or therapeutic policy. A problem includes all kinds of medical or nursing information that represents a health problem. A problem can represent various types of health problems:

• A complaint, finding by patient: a subjective, negatively experienced observation of the patient’s health. Examples: stomach ache, amnesia.
• A symptom: an observation by or about the patient which may indicate a certain disease. Examples: fever, blood in stool, white spots on the roof of the mouth.
• A diagnosis: medical interpretation of complaints and findings. Examples: Diabetes Mellitus type II, pneumonia, hemolytic-uremic syndrome.
• A functional limitation: a reduction of functional options. Examples: reduced mobility, help required for dressing.
• A complication: Every diagnosis seen by the healthcare professional as an unforeseen and undesired result of medical action. Examples: post-operative wound infections, loss of hearing through the use of antibiotics.

Purpose

An overview of a patient’s health problems has the purpose of informing all healthcare professionals involved in the patient’s care on the patient’s current and past health condition. It provides insight into which problems require medical action, which are under control and which are no longer current. The problem overview also directly provides medical context for medication administered and procedures carried out. The overview promotes an efficient, targeted continuation of the patient’s care. A complete list of problems is of importance for automated decision support and determining contraindications.